Hillsborough Pharmacy Birth Control Consult Patient Questionnaire

Name*

First NameLast Name

Birthday*

Date

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Age*

Today's Date*

Date

Insurance*

Primary Care or Women's Health Provider*

Practice Name of Above Provider*

Provider Phone Number*

Please enter a valid phone number.

Are you allergic to any Medications?*

YesNo

Medication Allergies (List name of medication(s) and your reaction to them)

Last Menstrual Period*

Date

Height (feet/inches)*

Weight (pounds)*

Are you currently taking a multi-vitamin or folic acid supplement?*

YesNo

If yes, which one(s)?

Multi-VitaminFolic Acid

Birth Control Method(s) You are Currently Using (check all that apply)*

What "Other" Birth Control Methods are you using?

Birth Control Methods You Would Like to Discuss and Consider at This Visit:*

What "Other" Birth Control Options Would You Like to Discuss or Consider at this Visit?

Birth Control History (list methods of birth control you've used in the past and any side effects or problems you've had with them)*

Do you think you might be pregnant? (Early signs and symptoms of pregnancy include a missed period, tender, swollen breasts, nausea with or without vomiting, increased urination and fatigue)*

YesNo

Did your last menstrual period start within the past 7 days?*

YesNo

Have you abstained from sex since your last menstrual period or delivery?*

YesNo

Have you used a reliable form of birth control consistently and correctly since your last period?*

YesNo

Have you had a miscarriage or abortion in the last 7 days?*

YesNo

Have you given birth in the last 4 weeks?*

YesNo

Have you given birth within the last six months, are you fully or nearly fully breastfeeding, AND have you had no menstrual period since the delivery?*

YesNo

Have you ever been told by a medical professional NOT to take hormones?*

YesNo

Have you ever received an organ transplant?*

YesNo

Do you have lupus?*

YesNo

Do you have, or have you ever had breast cancer?*

YesNo

Have you had diabetes for more than 20 years? or have you had diabetes with kidney disease (nephropathy), disease of the back of your eye (retinopathy), or nerve damage (neuropathy)?*

YesNo

Have you ever had a heart attack or stroke or been told that you had heart disease, including cardiomyopathy, heart failure, atrial fibrillation, and problems with your heart valve?*

YesNo

Do you have any other form of active cancer, including metastatic cancer, for which you are receiving therapy, or you are within 6 months of remission?*

YesNo

Do you have high blood pressure or hypertension? (Higher than 140/90)*

YesNo

Do you have, or have you ever had liver disease, hepatitis, liver cancer, or jaundice (yellowing of skin or eyes)?*

YesNo

Do you have, or have you ever had gallbladder disease and still have your gall bladder?*

YesNo

Do you have ulcerative colitis or Crohn's disease?*

YesNo

Do you have, or have you ever had a blood clot in your leg (Deep Vein Thrombosis/DVT or Superficial Venous Thrombosis) or lung (Pulmonary Embolism/PE)?*

YesNo

Have you ever been told by a medical professional that you have a blood disorder that increase your risk of developing a blood clot?*

YesNo

Have you had recent major surgery or are you planning to have major surgery in the next 4 weeks after which you had to or will have to have a long period of time with limited or no movement?*

YesNo

Are you both 35 years or older and smoke cigarettes or vape nicotine products?*

YesNo

Do you have multiple sclerosis with limited or no movement?*

YesNo

Do you have migraine headaches with aura (warning signs or symptoms such as flashes or light, blind spots, or tingling in your hands or face that comes and goes completely away before the headache starts)?*

YesNo

Do you have high cholesterol?*

YesNo

Do you have 2 or more of the following conditions? Check all that apply:*

Has it been less than 21 days since you have given birth or less than 30 days since you have given birth and you are breastfeeding?*

YesNo

Has it been less than 42 days since you have given birth?*

YesNo

If yes, do you have ANY risk factors for blood clots? See risk factors below, check all that apply to you*

Have you had Roux-en-Y, gastric bypass, or biliopancreatic surgery?*

YesNo

Do you take any of the following medications?*

Do you take any other medications for seizures, tuberculosis or Human Immuno-deficiency Virus?*

YesNo

If yes, list them here:*

I am requesting that my pharmacist consult with me about my birth control options. I understand the following:

The pharmacist is providing care based on the information I provide.

The pharmacist will review my birth control options, if pharmacist is able to provide my selected birth control method, they will review with me how to use to it, and what to expect.

The pharmacist is available to answer all my questions about certain birth control options. I understand pharmacists and physicians have different education and training.

If the pharmacist is unable to provide my desired method of birth control, I will be referred to my primary care or women's health provider.

Establishing a relationship with a primary care provider or women's health provider is important, so I should request information from the pharmacist about providers in my local area if I do not have one.

It is advised to have regular visits with a primary care or women's health provider to recieve recommended tests and screenings.

No method of birth control is 100% effective at preventing pregnancy.

Hormonal birth control does not start working right away to prevent pregnancy. After using hormonal birth control for 7 days, it will prevent pregnancy if used correctly and consistently.

Hormonal birth control does not protect against sexually transmitted diseases (STDs). Condoms protect against STDs.

I will contact my pharmacist and primary care provider or women's health provider regarding any side effects, problems, or changes to my health status or medications.

Sign and Date*

Date

Hour MinutesAM/PM Option